The anaesthetic management of patients undergoing caesarean section surgery and its impact on post-operative analgesia
Date
2016
Authors
Chetty, Sean
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Abstract
Poorly controlled pain following caesarean section surgery can have a
debilitating effect on the physical and emotional well being of a woman during
the post-operative period. Good intra-operative anaesthetic management
during caesarean section surgery is requisite to improve post-operative
analgesia, and thereby contribute to the well being of the patient.
In South Africa (SA) there are currently no national obstetric anaesthesia
practice guidelines. Anaesthetic service providers therefore rely on
knowledge acquired during their anaesthetic training and recommendations
from international guidelines (which may not be applicable in SA). In order to
establish a reference standard of anaesthetic care for obstetric patients in SA,
a semi-structured interview was conducted with the heads of department
and/or their representatives from the eight anaesthesiology academic
departments in SA in 2012. The experts provided recommendations on the
intra-operative anaesthetic management of patients for elective and
emergency caesarean sections, as well as the post-operative monitoring and
analgesic management of these patients. The recommendations were based
on the experts’ understanding of the uniquely local healthcare environment in
SA.
Following the establishment of the SA reference standard, a national survey
of anaesthetic service providers was conducted in 2014 to establish what the
practises are in South Africa for caesarean section anaesthetics. Ninehundred-
and-thirty-three survey responses were analysed, which equated to a
58% response rate. The majority of anaesthesia providers (97.8%) perform
single shot spinal anaesthesia for caesarean sections. Thirty percent of
respondents chose to use Quincke spinal needles, despite the increased risk
of this needle causing post-dural puncture headaches (PDPH). The preferred
local anaesthetic drug was 0.5% bupivacaine with dextrose, and fentanyl was
the most commonly used additive agent, as opposed to common international
practice, which advocates morphine. The survey also revealed that 58% of
doctors work in hospitals that do not have a post-operative monitoring
protocol for patients following caesarean section surgery. This contrasts to
recommendations suggested by the national experts regarding patient
monitoring requirements.
A clinical trial was then conducted to compare the analgesic efficacy of two
different doses of intrathecal morphine (50μg and 100μg) with 25μg fentanyl.
Patients in both morphine treatment groups had significantly lower postoperative
opioid requirements than patients in the fentanyl group. The pain
numerical rating scale (NRS) scores were however not statistically different
and there was also no difference in the side effects profile or emotional
parameters measured, between the groups.
This study highlights the differences in the recommended practise of obstetric
anaesthesia in SA compared to other countries and demonstrates how
obstetric anaesthesia is practised in SA. The final component of this study
has demonstrated how international best practices can be easily implemented
in SA to improve the anaesthetic care of the obstetric patient.
Description
A Thesis submitted to the Faculty of Health Sciences, University of the
Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree
of Doctor of Philosophy. 14th October 2016 in Johannesburg